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After the length of the menstrual cycle has been observed for at least 8 months, the following calculations are made: (1) The first fertile day is determined by subtracting 18 days from the shortest cycle, and (2) the last fertile day is determined by subtracting 11 days from the longest cycle For example, if the observed cycles run from 24 to 28 days, the fertile period would extend from the sixth day of the cycle (24 minus 18) through the 17th day (28 minus 11) Day 1 of the cycle is the first day of menses
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This method indicates the safe time for intercourse after ovulation has passed The temperature must be taken immediately upon awakening, before any activity A slight drop in temperature often occurs 12 24 hours before ovulation, and a rise of about 04 C occurs 1 2 days after ovulation The elevated temperature continues throughout the remainder of the cycle Data suggest that the risk of pregnancy increases starting 5 days prior to the day of ovulation, peaks on the day of ovulation, and then rapidly decreases to zero by the day after ovulation
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This fertility awareness method requires the use of a set of beads that reminds the couple to avoid intercourse (or use a barrier method of contraception) during days 8 through 19 of the menstrual cycle The beads are in a circle and color-coded to show the days when a woman is likely to become pregnant and the days that are safe during the cycle A movable ring is repositioned to a new bead each day starting on the first day of menses In a small multicenter trial, the perfect use failure rate was 5% and the typical use failure rate was 12% The method is applicable to women with a history of menstrual cycles between 29 and 32 days
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tol, 800 mcg, was 98% successful in terminating pregnancy at 8 weeks or less Minor side effects, such as nausea, vomiting, and diarrhea, are common with these regimens There is a 5 10% incidence of hemorrhage or incomplete abortion requiring curettage There is a recent report of four deaths occurring within 1 week of medical abortion, associated with endometritis and toxic shock caused by Clostridium sordellii To improve diagnosis and treatment of this entity, clinicians should be aware of the constellation of presenting symptoms of tachycardia, hypotension, edema, hemoconcentration, profound leukocytosis, and absence of fever
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ACOG ACOG practice bulletin: Clinical management guidelines of Obstetrician-Gynecologists Number 67, October 2005 Medical management of abortion Obstet Gynecol 2005 Oct;106(4):871 82 [PMID: 16199653] Fischer M et al Fatal toxic shock syndrome associated with Clostridium sordellii after medical abortion N Engl J Med 2005 Dec 1;353(22):2352 60 [PMID: 16319384] Grimes DA et al Induced abortion: an overview for internists Ann Intern Med 2004 Apr 20;140(8):620 6 [PMID: 15096333]
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Since the legalization of abortion in the United States in 1973, the related maternal mortality rate has fallen markedly, because illegal and self-induced abortions have been replaced by safer medical procedures Abortions in the first trimester of pregnancy are performed by vacuum aspiration under local anesthesia or with medical regimens Dilation and evacuation, a variation of vacuum aspiration is generally used in the second trimester Techniques utilizing intra-amniotic instillation of hypertonic saline solution or various prostaglandins regimens, along with medical or osmotic dilators are occasionally used after 18 weeks Overall, legal abortion in the United States has a mortality rate of less than 1:100,000 Rates of morbidity and mortality rise with length of gestation Currently in the United States, 87% of abortions are performed before 13 weeks gestation and only 14% are performed after 20 weeks If abortion is chosen, every effort should be made to encourage the patient to seek an early procedure While numerous state laws limiting access to abortion and a federal law banning a rarely-used variation of dilation and evacuation have been enacted, abortion remains legal and available until fetal viability under Roe v Wade Complications resulting from abortion include retained products of conception (often associated with infection and heavy bleeding) and unrecognized ectopic pregnancy Immediate analysis of the removed tissue for placenta can exclude or corroborate the diagnosis of ectopic pregnancy Women who have fever, bleeding, or abdominal pain after abortion should be examined; use of broad-spectrum antibiotics and reaspiration of the uterus are frequently necessary Hospitalization is advisable if acute salpingitis requires intravenous administration of antibiotics Complications following illegal abortion often need emergency care for hemorrhage, septic shock, or uterine perforation Rh immune globulin should be given to all Rh-negative women following abortion Contraception should be thoroughly discussed and contraceptive supplies or pills provided at the time of abortion Prophylactic antibiotics are indicated; for example a one-dose regimen of doxycycline, 200 mg orally 1 hour before the procedure Many clinics prescribe tetracycline, 500 mg four times daily for 5 days after the procedure, as presumptive treatment for Chlamydia Long-term sequelae of repeated induced abortions have been studied, but as yet there is no consensus on whether there are increased rates of fetal loss or premature labor It is felt that such adverse sequelae can be minimized by performing early abortion with minimal cervical dilation or by the use of osmotic dilators to induce gradual cervical dilation A population-based study showed no evidence of an increased risk of breast cancer in women who had undergone an induced abortion Mifepristone (RU 486) is approved by the FDA as an oral abortifacient; the dose is 600 mg orally on day 1 It is followed by 400 mcg orally of misoprostol (a prostaglandin) on day 3 This combination is 95% successful in terminating pregnancies of up to 9 weeks duration with minimum complications Although not approved by the FDA for this indication, a combination of intramuscular methotrexate, 50 mg/m2 of body surface area, followed 7 days later by vaginal misopros-
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